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2019 Participation Guide
facs.org/mbsaqip
The Metabolic and Bariatric Surgery Accreditation
and Quality Improvement Program (MBSAQIP) has
been approved as a Qualified Clinical Data Registry
(QCDR) for the 2019 performance year
QUALIFIED CLINICAL DATA REGISTRY
Table of Contents
QUALIFIED CLINICAL DATA REGISTRY
Welcome 3MBSAQIP QCDR Comprehensive Checklist 4CMS Merit-based Incentive Payment System (MIPS) 6MBSAQIP QCDR 8
What Is a QCDR?
What Are Improvement Activities?
Public Reporting
What Are the Benefits of Submitting Data through the MBSAQIP QCDR?
What Are the Requirements for Successful Participation in MIPS Reporting Using the MBSAQIP QCDR?
2019 MBSAQIP QCDR Outcome Measures
How to Submit My Measures 10Resources 11
3
WelcomeA message from the Program Administrator
Centers participating in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) program—offered by the American College of Surgeons (ACS) in partnership with the American Society for Metabolic and Bariatric Surgery (ASMBS)—capture 100 percent of metabolic and bariatric cases into the MBSAQIP data registry. The efforts by participating centers have allowed the MBSAQIP data registry to successfully participate as a Qualified Clinical Data Registry (QCDR) in the Center of Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) Quality reporting (formerly PQRS).
The MBSAQIP offers one of several options whereby a surgeon can elect to submit their quality data measures for successful MIPS participation. The QCDR reporting option enables MBSAQIP to develop its own quality measures that are relevant, clinically appropriate, and actionable for metabolic and bariatric surgeons.
MBSAQIP is pleased to provide this MIPS participation option through the MBSAQIP for all surgeons whose data is captured in the MBSAQIP data registry. Feedback Reports are available to all surgeons who have cases collected in the MBSAQIP registry as a means to improve their outcomes before final submission of the Risk-Standardized data to the CMS and reporting data publicly. Within this guide, you will find timelines, requirements for participation, and specific guidance based on your role at the center to use the MBSAQIP QCDR for MIPS participation.
As always, we thank you for your support of the MBSAQIP and for all that you doto meet the needs of the metabolic and bariatric surgery community.
Sincerely,
Teresa Fraker, MS, RNProgram Administrator, MBSAQIPDivision of Research and Optimal Patient CareAmerican College of Surgeons
QUALIFIED CLINICAL DATA REGISTRY
MIPS QCDR SUBMIT MY MEASURES RESOURCES
Participation Guide | MBSAQIP Qualified Clinical Data Registry (QCDR) 4
QCDR CHECKLIST
MBSAQIP QCDR Comprehensive ChecklistDate* Center’s Primary Contact MBSAQIP Surgeon
October 14–31, 2019 �Receive e-mail from MBSAQIP that QCDR portal is ready for 2019.
�E-mail Primary Contacts to announce that the QCDR portal is ready for 2019.
October 14– December 2, 2019
�Check if your surgeons are required to participate in MIPS for the 2019 performance year. Enter Surgeon’s National Provider Identifier (NPI) at qpp.cms.gov/participation-lookup. If surgeons are not eligible, no need to continue to the next step. �Check with your MBS Director, Center’s Administration, and/or Surgeon’s Office Practice Manager who is designated to submit MIPS quality measures data to determine whether the MBSAQIP QCDR is the best option to participate in MIPS reporting. If your center is participating in MIPS through another means (for example, GPRO), no need to continue to the next step. �Log in to the QCDR portal to enter or verify surgeon’s correct e-mail address. (if correct e-mail is already listed, no action is required). An invitation email will be sent to the surgeon in December 2019. �Verify Tax Identification Number (TIN) and provide to surgeon(s). The TIN must match field 25 of the CMS-1500 claim form for Medicare billing. An incorrect TIN may result in unsuccessful participation in MIPS.
*Dates are tentative
MIPS QCDR SUBMIT MY MEASURES RESOURCES
Participation Guide | MBSAQIP Qualified Clinical Data Registry (QCDR) 5
QCDR CHECKLIST
Date* Center’s Primary Contact MBSAQIP Surgeon
December 16, 2019 �Provide Feedback Reports 1 and 2 and alert surgeons.
�Receive an e-mail invitation to participate in the MBSAQIP QCDR after center’s Primary Contact has submitted e-mail address. Note: If you did not receive an e-mail and you would like to participate, please contact your center’s Primary Contact. �Check if you are eligible to participate in MIPS for the 2019 performance year (enter your NPI at qpp.cms.gov/participation-lookup). �Verify Tax Identification Number (TIN) with Center’s Primary Contact or Practice Manager. �Enter correct TIN (the NPI/TIN combination is used for Medicare Part B participation and billing), and electronically sign the 2019 Consent to Disclose Data to gain access to the QCDR portal. Note: A new consent must be signed each year, and submitting this form does not submit quality measures to CMS. �Receive username and password via e-mail after consent is signed. �Receive e-mail regarding Feedback Reports 1 and 2, and log in to QCDR portal to view it.
February 17, 2020 �Provide Feedback Report 3 and Risk Standardized Report and alert surgeons.
�Receive e-mail regarding Feedback Report 3 and Risk Standardized Report and log into QCDR portal to view it.
February 17– March 2, 2020
�Remind surgeon(s) to view Risk Standardized Report and attest to any Improvement Activities (IAs). � If you are submitting the quality data and IAs on behalf of the surgeon, please check/communicate with the surgeon on selecting appropriate IAs.
�Log in to the QCDR portal to view Risk Standardized Report. �Attest to any Improvement Activities (IAs) that you performed in 2019. �Select whether or not to send your quality data and/or IAs to CMS and provide an electronic signature. Your data will not be submitted to CMS until you complete this step.
March 27, 2020 �Submit selected Quality Data and/or Improvement Activities (IAs) to CMS.
May 11, 2020 �Provide Feedback Report 4 and alert surgeons.
�Receive e-mail regarding Feedback Report 4, and log in to QCDR portal to view it.
MBSAQIP QCDR Comprehensive Checklist (continued)
*Dates are tentative
QCDR CHECKLIST QCDR SUBMIT MY
MEASURES RESOURCES
Participation Guide | MBSAQIP Qualifi ed Clinical Data Registry (QCDR) 6
MIPS
CMS Merit-based Incentive Payment System (MIPS)The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 introduced the new Quality Payment Program (QPP) with two tracks for surgeons to participate: the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). MIPS is the QPP track most physicians will (initially) participate in. In 2019, the MBSAQIP Data Registry was approved as a QPP MIPS Qualified Entity.
The benefits of submitting data through MBSAQIP for the purposes of QCDR are outlined on page 8 of this information packet. Three previous programs—EHR Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-based Modifier (VM)—were consolidated into the new Merit-based Incentive Payment System (MIPS) program.
How much can MIPS adjust payments?
2019 2020 2021 2022 onward
QCDR CHECKLIST QCDR SUBMIT MY
MEASURES RESOURCES
Participation Guide | MBSAQIP Qualifi ed Clinical Data Registry (QCDR) 7
MIPS
2019 MIPS categories include the following:
• Quality (formerly PQRS)
• Promoting Interoperability (PI, formerly Advancing Care Information)
• Improvement Activities (IA)
• Cost
For additional information around ACS efforts to assist surgeons with MIPS participation, visit
facs.org/qpp
For additional information on the 2019 Quality Payment Program, visit
bulletin.facs.org/2019/01/what-to-expect-from-the-2019-quality-payment-program/
QCDR CHECKLIST MIPS SUBMIT MY
MEASURES RESOURCES
Participation Guide | MBSAQIP Qualifi ed Clinical Data Registry (QCDR) 8
QCDR
MBSAQIP QCDRWhat Is a QCDR?
A QCDR is a CMS-approved entity (registry) that collects clinical data for the purpose of patient and disease tracking to improve quality of care provided to patients in a particular population. As noted above, individual surgeons who satisfactorily participate in 2019 MIPS reporting through a QCDR may avoid the 2021 negative payment adjustment on total Medicare Part B covered professional services in 2019. If a surgeon participates in a group (such as GPRO) or virtual group, individual surgeons do not need to also participate in MIPS reporting via MBSAQIP QCDR. Additionally, participating in the MBSAQIP QCDR will not satisfy the Promoting Interoperability (PI, formerly Advancing Care Information) category of MIPS.
What Are Improvement Activities?
Improvement Activities (IA) is a category under MIPS that requires clinicians to attest to participation in activities that improve clinical practice. Bariatric surgeons can choose from over 80 weighted activities.
A list of all activities can be found on our website at facs.org/quality-programs/mbsaqip/resources/data-registry.
Public Reporting
The MBSAQIP QCDR measures may be publicly reported if the surgeon participates in the MBSAQIP QCDR and authorizes data submission to the CMS 2019 MIPS program year.
What are the benefits of submitting data through the MBSAQIP QCDR?
• Data is already being collected at your center as part of participation in the MBSAQIP, whereas other options to satisfy MIPS reporting may require additional data burden on the physician.
• The measures are more relevant, meaningful, and actionable and can help with quality improvement.
• There is greater potential to meet the reporting requirement of six measures.
• The Merit-based Incentive Payment System (MIPS) is a new payment mechanism that will provide payment adjustments to Medicare Part B payments two years after the performance year. Successfully reporting on the MIPS Quality category measures through the MBSAQIP QCDR is one category to avoiding Medicare Part B payment penalties in 2021.
• We provide an opportunity for metabolic and bariatric surgeons to engage in quality improvement initiatives and fulfill the MIPS Improvement Activity component as well as the Practice Improvement requirement for the American Board of Surgery’s Continuous Certification.
Note: Participation in the MBSAQIP QCDR has no impact on the center’s accreditation status.
QCDR CHECKLIST MIPS SUBMIT MY
MEASURES RESOURCES
Participation Guide | MBSAQIP Qualified Clinical Data Registry (QCDR) 9
QCDR
What are the requirements for successful participation in MIPS reporting using MBSAQIP QCDR?
To be eligible for a positive payment adjustment in 2021 by individually reporting through the MBSAQIP QCDR, the surgeon should:
1. Have billed Medicare for $90,000 or more AND provided care for more than 200 Medicare patients AND provided 200 or more covered professional services to Medicare patients in 2019 (check eligibility online at qpp.cms.gov/participation-lookup).
2. Successfully report six (6) individual measures.
3. At least 60 percent of the provider’s applicable patients (patients with primary Laparoscopic Sleeve Gastrectomy or Laparoscopic Roux-en-Y Gastric Bypass) seen during the performance period (calendar year 2019) must have operation dates during January 1–October 15, 2019.
4. Attest to the appropriate Improvement Activities (IAs) combinations to get the maximum score.
2019 MBSAQIP QCDR Outcome Measures
1. Risk standardized rate of patients who experienced a postoperative escalation in care event within 30 days
2. Risk standardized rate of patients who experienced a pulmonary complication within 30 days
3. Risk standardized rate of patients who experienced extended length of stay (> 3 days) within 30 days
4. Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days
5. Risk standardized rate of patients who experienced an unplanned reoperation within 30 days
6. Risk standardized rate of patients who experienced an unplanned readmission within 30 days
Feedback Report Operation Dates Lock Date Data Amount
1 January 1–March 31, 2019 June 29, 2019 3 months
2 April 1–June 30, 2019 September 28, 2019 3 months
3 July 1–September 30, 2019 December 29, 2019 3 months
Risk-Adjusted Report January 1–October 15, 2019 January 13, 2020 9.5 months
4 October 1–December 31, 2019 March 30, 2020 3 months
QCDR CHECKLIST MIPS QCDR RESOURCES
Participation Guide | MBSAQIP Qualifi ed Clinical Data Registry (QCDR) 10
SUBMIT MY MEASURES
The submission deadline is March 2, 2020.
The MBSAQIP will not submit any quality measures outcomes data to the CMS without surgeons’ authorization.
How to Submit My Measures
Submission Steps for March 2020
Step 1: Log in with your username and password Step 2: Select Reports from the menu bar
Step 3: Select the hyperlinked Risk Standardized MBSAQIP QCDR Quality Measure Outcomes Report 2019
Step 4: Review your data
Step 5: Attest to any Improvement Activities that you completed in 2019
Step 6: Provide your electronic signature after reading the attestation, and submit your option (A or B) to the MBSAQIP by clicking Submit to MBSAQIP
QCDR CHECKLIST MIPS QCDR SUBMIT MY
MEASURES
Participation Guide | MBSAQIP Qualified Clinical Data Registry (QCDR) 11
RESOURCES
MBSAQIP Staff Contact Information
General QCDR [email protected]
Rasa Krapikas Data Registry [email protected]
Kim Evans-Labok Project [email protected]
Teresa Fraker Program [email protected]
Surgeon Specific [email protected]
Resources
